Legislative hurdles
A new group of bills
is creating dialogue on how chiropractic will be seen by the government. The
effects of these legislative projects are sure to influence the way you do business.
By Randy Southerland
In the halls of Congress
powerful legislators have shown increasing willingness to champion chiropractic—particularly
in its quest to be more fully included in Federal programs such as Medicare
and the Veterans Administration.
Yet, even as the profession seems poised on the edge of greater acceptance and
more opportunity, the in-fighting over these bills has brought into sharp relief
the deep chasm that separates philosophies. Straight vs. mixer and ICA vs. ACA
have long formed the dividing lines in a profession that often hasn’t
been able to reach a consensus on what it does (and what it truly is) as a healthcare
profession.
While all major chiropractic associations and groups agree that chiropractic
services should be included in federal health care programs, the shape and scope
of that inclusion has produced sharp differences on both substance and tactics.
It has, for example, produced two vastly different legislative proposals that
take very divergent approaches to strengthening the profession’s inclusion
in Medicare.
DEMONSTRATING
Last spring, an amendment by Iowa Sen. Charles Grassley (R) creating a demonstration
project to reimburse chiropractors for additional services joined a number of
add-ons to the $400 billion prescription drug bill for seniors.
Supported by the American Chiropractic Association (ACA), this measure would
create a half dozen demonstration sites in which Medicare would reimburse DCs
for services the program now pays other health providers to perform. These services—which
DCs are not reimbursed for now—would have to be within their scope of
practice in that particular state.
“This gives the chiropractic profession the opportunity to end discriminatory
treatment that we’ve been faced with under Medicare and to compete on
an equal footing with other professionals who provide the same services that
chiropractors are licensed to provide, but cannot,” says Jon Hymes, ACA
vice president for governmental relations.
Medicare has for many years only reimbursed chiropractors for adjustments.
By providing more preventive
services, the ACA and others contend Medicare could save money in the long run
because patients would not have to receive more expensive medical care. Results
from the project would be studied to determine if cost savings are obtained
by allowing DCs to provide these services. Eventually this data could be used
to argue for expanding coverage to the rest of the Medicare system.
At the same time, the bill would be relatively inexpensive, compared to the
billions being spent on a drug benefit.
“It’s deemed for the purposes of this bill (to be) budget neutral,”
says Hymes. “The Congressional Budget Office has looked at the cost of
this three year demonstration and they say in their budget document that the
provision will result in a cost or savings of less than $50 million.”
While the ACA has organized a grass roots campaign to help sway allies in the
U.S. House to accept the demonstration project as well, there has been little
support for the measure from other professional associations. The International
Chiropractors Association (ICA) hasn’t taken a position for or against
the bill, according to Executive Director Ron Hendrickson.
Many have raised concerns that yet another chiropractic demonstration project
would hinder efforts to expand Medicare coverage for X-rays and exams.
“They tend to have a huge delaying effort on program-wide reform,”
says Hendrickson.
A similar demonstration project was enacted in the Department of Defense and
has been used by opponents to slow the commissioning of DCs as officers in the
Armed Services. The demonstration project has continued while real reform has
been put on the back burner, critics charge.
“Congress has a tendency to say ‘Let’s wait until the demonstration
project is done and see how things look,’” observes Michael McLean,
a Virginia Beach, Va., chiropractor, who serves as chairman of the ICA Legislative
Committee. “Experts say it might be eight years before the demonstration
project produces results. During that time it would be difficult to get things
done, such as payment for X-ray and exams.”
ADJUSTMENT IS OURS
While the Grassley amendment has stirred little active opposition, another Medicare
measure introduced by Illinois Representative Don Manzullo (R) has drawn considerable
criticism from the ACA.
Known as the Chiropractic Medicare Freedom and Benefit Protection Act, HR 2560
would set up a separate classification for doctors of chiropractic. The Chiropractic
Coalition—made up of the ICA, World Chiropractic Alliance (WCA) and the
Federation of Straight Chiropractors and Organizations (FSCO)—actively
supports this bill.
“It would actually state what it is we do—that is a chiropractic
adjustment—and that it’s not done by any other profession,”
says McLean. “Thus, nobody else would be able to bill for our services.”
The bill is designed to clearly define that the chiropractic adjustment is different
from osteopathic health care or other forms of manipulation performed by other
professionals. While chiropractors are considered the primary providers of manipulation
as a covered physician service, the federal government has determined that they
are not the only professionals who can provide this service. Osteopaths and
others who fall under the physician category can also provide and bill for this
service using the same AMA-CPT codes.
“If you lump DCs in with MDs, osteopaths and other ‘physicians’
using a generic CPT code—as though there were no difference between any
of them—it is inevitable that the medical physicians will get the lion’s
share of the money, and a good part of the chiropractors’ share as well,”
wrote WCA President Terry Rondberg in an email to James D. Edwards, chairman
of the ACA’s Board of Governors. “Because we would be in another
section, we would not be subject to medical necessity,” adds McLean. “That’s
difficult if you have a medical profession that doesn’t believe chiropractic
is ever necessary.”
The bill also adds a provision to the Medicare law that defines chiropractic
services as “clinically necessary care by means of adjustment of the spine
(to correct a subluxation) performed by a chiropractor legally authorized to
perform such adjustment by the State or jurisdiction in which such care is provided.”
Chiropractors would be able to conduct physical exams, take X-rays and use other
instruments “used in the practice of chiropractic.” This provision
would also make it easier to obtain Medicare reimbursement for these services—none
of which are now covered.
Successful passage of the bill—which even supporters admit is far from
certain—could result in the creation of new billing codes for the chiropractic
adjustment. Medicare currently uses AMA-CPT codes.
It is this change in the physician status of DCs that has raised an alarm within
the ACA. Without the ability to use Evaluation and Management (E&M) codes,
chiropractors might be relegated to utilizing the non-physician level Evaluation
and Assessment (E&A) codes. These codes pay substantially less in reimbursements
under Medicare. Other third party payers who use the same fee schedule might
also pay substantially less to the chiropractors, according to an analysis released
by the ACA.
ICA officials, on the other hand, counter that the bill won’t result in
lower reimbursements.
“There’s no real evidence [that there would be lower payments],
and it could just as easily create an increase in payment for the chiropractic
service,” says McLean. “That’s to be determined and that’s
not something that’s a foregone conclusion.”
The ACA also opposes changing “manual manipulation of the spine to correct
a subluxation” to “adjustment of the spine to correct a subluxation”
because it might also result in the value of the service being reduced.
An analysis written by ACA legal counsel Tom Daly, an attorney at the Fairfax,
Va., law firm of Odin, Feldman & Pittleman, P.C., focuses on the importance
of defining chiropractic care.
“The proposed change in the statutory language would require a new definition,
as well as the assessment of a new relative value for the ‘adjustment’
service,” writes Daly. “Such a process would provide an opportunity
for the opponents of the chiropractic profession to argue against the implementation
of the existing relative values for the CMT codes, and for the implementation
of lower relative values comparable to physical medicine codes.”
SERVING VETS
Differences in philosophy have also become evident in the work being done by
the Chiropractic Advisory Committee to the Secretary of Veterans Affairs. This
group of DCs and representatives from other healthcare professions has been
engaged in crafting a series of recommendations for the inclusion of chiropractic
services in the VA’s extensive network of hospitals and outpatient clinics.
This effort is poised to get a further boost with the expected passage of the
Veterans Health Care Improvement Act (HR 2357) by the House of Representatives.
The bill contains a provision giving the VA the authority to hire and employ
chiropractors as regular employees on a par with MDs and other health care professionals.
Legislation passed in 1999 (P.L. 106-117) required the agency to develop a plan
for offering chiropractic care.
“Up to this point there has never been a chiropractor hired by the federal
government as a chiropractor,” explains McLean, a member of the advisory
committee. “There’s no pigeon hole in the federal employment system
into which you can put a chiropractor.”
This new legislation would establish pay grades and benefits along with opportunities
for advancement in the Federal system.
“It would create a category of employment in the federal government known
as Doctor of Chiropractic,” says McLean. “In the past, chiropractors
could be hired on a temporary basis, but could not be permanent employees. There
was no job class for them.”
Under this new classification DCs will be treated similarly to other health
care providers such as podiatrists and optometrists. While the pay grade is
likely to be close to that of a medical doctor, it will most likely not contain
provisions for higher salary grades based upon areas of specialization.
While the job classification issue seems to be solved, other thorny issues are
still to be worked out by the committee, which must submit a set of recommendations
before its authorized life ends in late 2004. The most contentious of these
issues has been over whether veterans will be able to have direct access to
chiropractors or if they must first get a referral from a VA medical doctor
who acts as the coordinator of the patient’s care.
“We’re very concerned about placing that sort of barrier in front
of the veteran who really deserves to have care if he needs it,” explains
McLean.
Direct access, however, raises the question of whether the DC might have to
perform the initial work-up and exam needed to admit a patient into a hospital
setting. Since few chiropractors have the skills and training of a primary care
physician, it is unlikely they would be able to conduct this process.
“So we’re trying to find some sort of middle ground that will be
more acceptable and more appropriate for the veteran whose welfare we really
have to keep utmost in mind,” he explains.
The advisory committee membership includes six chiropractors, two medical doctors,
an osteopath, a physician’s assistant and a physical therapist—all
of whom bring widely varying points of view on what role chiropractic should
play in this healthcare system.
Even the chiropractic members represent contradictory points of view. For example,
Charles E. DuVall Jr. serves as president of the National Association of Chiropractic
Medicine—an organization that advocates a limited role for chiropractic,
and has labeled some of the profession’s practices as unscientific quackery.
The committee has also engaged in extensive discussion on the proposed scope
of practice for DCs in the VA. The limits on practice will likely be determined
by the laws of the state in which the doctor is licensed, as well as the individual
environment of the facility.
Since most VA facilities are already well-stocked with physical therapists and
X-ray technicians, it’s unlikely that a DC would be called upon to provide
these services. Someone other than the chiropractor may even perform exams.
“It’s important to realize that what the VA needs from us is not
medical abilities,” says McLean. “They already have lots of medical
doctors to do medical things. The things they need from us are the things that
are not being done, which is primarily adjusting.”
Fully integrating chiropractors into the VA may very well change the way this
mammoth system works. Veterans will have access to a different kind of care
than they have in the past. In addition, the more than 50 percent of medical
doctors who receive their training in VA facilities will have to learn to work
with and get along with a profession they have largely ignored.
At the same time chiropractic may very well be changed. DCs who have functioned
as independent practitioners outside the health care system must also learn
to work with the Allied Health Professions.
“It will be our challenge to function as part of a team and still apply
our chiropractic tenets and philosophy within that team,” says McLean.
Chiropractic colleges will be pushed to begin training their students to function
in this system as well. They too may be compelled to form alliances with hospitals
and the medical community to provide these training opportunities.
While opposing elements within chiropractic have continued to battle to advance
their own visions of the path that it should follow, changes seem inevitable.
And even though the chiropractic profession will have a role in shaping its
own path, in part, the direction and scope of the profession will also likely
be determined by others—legislators—and the health care system in
which it is seeking its own place.
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